Clinical Review Nurse: Complex Case Mgmt & PA

Akido; Chino (CA); On-site; USD 78,000 - 103,000; Full time

Job summary

Akido Labs, Inc. is seeking a Clinical Review Nurse to focus on complex case management and prior authorization within a California managed care setting. You will review outpatient requests, analyze medical necessity, and ensure timely determinations in collaboration with Medical Directors and providers.

The role emphasizes adherence to MCG criteria, DMHC/CMS regulations, and EZCap-based documentation, with opportunities to expand into complex case management as the program grows.

Qualifications

• 3-5+ years of current clinical UM review
• Experience with prior authorization in managed care or delegated environment
• Experience with complex case management
• Knowledge of MCG criteria, medical necessity review, and prior authorization workflows
• Experience with EZCap (preferred)
• Experience in a delegated MSO or health plan environment (preferred)
• Knowledge of California managed care regulations (DMHC/CMS)
• Strong clinical assessment skills and attention to detail
• Effective written and verbal communication
• Ability to manage competing priorities in a fast-paced environment

Responsibilities

• Review and process prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, and DME and ancillary services
• Evaluate requests using MCG guidelines and health plan criteria and policies
• Review medical records and supporting clinical documentation to ensure completeness, accuracy, and medical necessity in accordance with established clinical guidelines and health plan requirements
• Identify missing or insufficient documentation and coordinate with providers for additional information
• Support case management for members with complex or high-risk care needs, including care coordination and follow-up
• Ensure all clinical determinations are properly documented in the system
• Maintain compliance with DMHC prior authorization requirements, CMS guidelines, health plan delegation standards, turnaround times, notification requirements, and documentation standards
• Communicate with physicians, medical groups, facilities, and ancillary providers to obtain additional clinical information and provide authorization status updates as needed
• Identify cases requiring clinical review and prepare clinical summaries for Medical Director determination
• Ensure cases requiring denial are routed appropriately to the Medical Director
• Document all authorization activities accurately within EZCap, maintaining detailed notes, status updates, and decision rationale
• Collaborate with UM Coordinators, Claims, Eligibility, and Operations
• Conduct comprehensive assessments and contribute to development of patient-centered care plans in collaboration with Medical Director
• Perform monthly care management outreach, medication review, and specialist/community resource coordination, documenting time and activities

Skills

Clinical UM review

Prior authorization

Complex case management

Communication skills

Attention to detail

Priority management

Tools

EZCap

MCG guidelines

Job description

Akido Labs, Inc. is seeking a Clinical Review Nurse to focus on complex case management and prior authorization within a California managed care setting. You will review outpatient requests, analyze medical necessity, and ensure timely determinations in collaboration with Medical Directors and providers.

The role emphasizes adherence to MCG criteria, DMHC/CMS regulations, and EZCap-based documentation, with opportunities to expand into complex case management as the program grows.